Client Name
Capella University
NURS-FPX6618: Leadership in Care Coordination
Instructor’s Name
August 2024
Planning and Presenting a Care Coordination Project
Slide 2: Hello everybody, I am _____. As a care coordinator project manager in UnitedHealth Group, today I would like to present a care coordination project plan. This plan aims to address the health needs of elderly patients having type 2 diabetes through the implementation of patient-centered care including a telehealth system. Telehealth systems will provide effective timely treatment to older adults through the use of remote technology or telemedicine strategy.
This system will ensure the improvement of self-management education for the patients with the coordination of interdisciplinary teams and stakeholders (Bendowska & Baum, 2023). The collaboration will provide collective expert opinion regarding the provision of effective care coordination to the patients. The result of the application of new technology is to enhance the experience of patients and reduction in healthcare costs through a decrease in hospital readmissions and traditional emergency department overloading. This system will provide timely intervention to the health issues thus preventing health disparities.
Purpose
Slide 3: Care coordination holds great significance in providing health and high-quality care to older adults suffering from diabetes (Northwood et al., 2022). The purpose of this presentation is to identify the care coordination needs of older adults and define a specific plan to address those needs. Older adults are vulnerable to this disease due to limited healthcare resources, lack of education regarding diabetes management, diabetic diet, medications, and insufficient transportation resources. This presentation aims to provide strategies to provide care coordination to older adults along with the identification of the people and resources that need to be available for the effective provision of coordinated care (Northwood et al., 2022). It will also focus on the milestones of the plan and the expected outcome measures to effectively evaluate the implementation of the project. In the end, it will be presented to decision-makers to determine its effectiveness and worth.
Vision of Interagency Coordinated Care for Elderly People
Slide 4: To address the care coordination needs of elder adults it is necessary to identify their preferences and beliefs so that the plan would be exactly according to the patient’s expectations (Nicolet et al., 2023). The goal of interagency coordinated care is to validate the cooperation of different organizations and agencies in providing high-quality standardized care coordination to elder people for better outcomes and improved experiences. This coordination will increase the positive experiences of elder people, improve in quality of health and care, reduction in health disparities, decrease hospital readmissions, and increase social health collaboration. Through the integration of various agencies and healthcare providers, the vision of providing health to the entire population will become a reality for a greater better cause.
Ideas for Organizing and Consolidating Care
Slide 5: The proper arrangement and maintenance of healthcare resources are necessary to ensure the effective implementation of care coordination for elderly people (Karam et al., 2021). This organizing process will involve the healthcare providers to communicate effectively for the designing and development of policies, strategies, and plans to provide coordinated care to the people. Different healthcare agencies and services need to work together for a single cause of providing standard health and safety to patients. A few ideas for organizing and consolidating care are given below;
- Developing a care-coordinated network for the elder people to unify all the healthcare professionals under a single platform for the unified care coordination plan.
- Mutual electronic health records (EHR) should be implemented to ensure that the data regarding the health of patients is accurately shared with all the interdisciplinary team members to present effective solutions (Robertson et al., 2022).
- An approach revolving around the patient requires plans that address the health requirements of the individual patient to better understand their health solution.
- Remote care facilities should be provided to elder people as they are unable to pay regular hospital visits due to isolated infographic locations or lack of transportation resources.
- A unified contact address should be provided to all the patients for effective communication between the patient and the care provider.
Underlying Assumptions and Uncertainties
The consent of all healthcare organizations on implementing patient patient-centered approach and use of EHRs is an assumption (Butler et al., 2020). This is also an assumption that sufficient financial resources will be available to hire staff for care coordination along with maintaining the remote technological systems. The participation of all the agencies is the major uncertainty that might be all the organizations are not interested in cooperation regarding care coordination. The privacy concerns of the patients will be raised due to the sharing of data with various agencies and healthcare professionals.
Participation of Organizations and Groups in Coordinated Care
Slide 6: Participation of various groups and organizations is needed to ensure the effective provision of coordinated care to elderly people (Khatri et al., 2023). The most important care coordination providers include specialists, nursing staff, primary care providers, different health agencies, and mental health providers. They all together play an efficient role in maintaining, and monitoring the health condition of the elders and the precautionary measures that are needed to be provided. Profitable or non-profitable organizations, social groups, and governmental agencies are all involved in the proficient implementation of healthcare services. A list of a few organizations and agencies involved in care coordination is given below;
Healthcare Professionals
Healthcare professionals and specialists are the most important components of providing coordinated care to the elders. Their disease diagnosis and proper medications help the patients maintain their health and act effectively under the instructions provided by the primary care providers for enhanced health outcomes.
Information Technology Experts
The involvement of information technology related to healthcare makes it the need of time to involve IT experts in the care coordination process so that they can effectively organize and maintain the technology-based healthcare systems to remove any kind of harm and cyber attack on patient information regarding medical history (Junaid et al., 2022). The use of EHR and telehealth services needs proper maintenance and security of patient data for which the advanced team and the systems are required to prevent data breaches.
Institutes of Education and Training
The plans and strategies can not be affected if the people of the community or the country are uneducated and have no knowledge regarding their health conditions and the follow-up with the doctors and specialists (Shahid et al., 2022). Self-management training should be provided to the patients so they can effectively, monitor their vital signs and prevent any deteriorating conditions by timely consulting with their healthcare providers.
Governmental Institutes and Agencies
Governmental agencies hold great significance in providing coordinated care to the elder people as they have the legal authority to pass the laws and rules that can bind the other agencies to integrate careful measures for the provision of high-quality health and safety to the elderly people.
Environment and Provider Capabilities
Slide 7: The environmental factors including isolated geographic locations, poor socioeconomic status, and cultural and language barriers serve as a cornerstone in decision-making regarding the provision of care coordination (Irani et al., 2019). Moreover, the capabilities of providers including their staff availability, IT experts, organizational infrastructure, or partnership with other agencies will decide the type of care coordination provided to the elder people. All these factors are responsible for the effective implementation of care coordination strategies in the areas and communities that do not have enough resources and capabilities to avail the opportunity of enhanced healthcare facilities and healthcare professional team collaboration in providing enhanced care and safety to the patients.
Resource Needs of a Population
Slide 8: Resources are required to provide effective healthcare to patients and maintain high-quality standards of clinical services (Young & Smith, 2022). The limited resources lead to health disparities resulting in an increased number of health problems both for the organization and the patients. A few resources needed for the care coordination of the elderly population are given below;
Healthcare Resources
Sufficient staff and healthcare professionals are needed to ensure that the patient’s problems are effectively recognized and responded to without any health harm. An adequate staff will efficiently respond to deteriorating health conditions and reduce the rate of hospital readmissions.
Community Resources
The support of community groups and healthcare agencies is the major resource in implementing effective care coordination for the elderly population. The community agencies can provide immediate healthcare assistance to the patients thus preventing harmful events.
Healthcare Information Technology Resources
Information technology holds great significance in ensuring high-quality health and security for patients by integrating effective technology-based systems for the early intervention of healthcare professionals.
Financial Resources
Financial resources are needed to ensure the proficiency of nay care coordination strategy applied for the specific population as without a proper budget the quality can not be maintained which results in poor patient outcomes.
Educational Resources
Providing proper education to people regarding their health situations and effective monitoring by following the instructions provided to them by their healthcare professionals is the end of time.
Assumptions and Uncertainties
All the community agencies and support groups have the capacity and ability to provide effective coordination along with financial stability is an assumption. Most rural community-based healthcare organizations are not able to integrate technology into their clinical setting which can be an uncertainty for the effectiveness of the care coordination plans.
Project Milestones
Slide 9: The proper planning of the coordinated care project needs milestones that can be divided into different planning phases for the smooth implementation of the coordinated care plan. The milestone helps in achieving the goal step by step to better maintain the quality standards and reduce errors (Yaghmour et al., 2021). The milestones of the coordinated care plan for the elderly population are given below;
Planning and Designing of the Project
The first phase includes the planning of the plan by identifying the needs of the healthcare population and their preferences. After the identification the design or layout of the plan will be developed to ensure the effectiveness of the process.
Development of the Project
The next phase of the planning and designing is the development of the project including the hiring of healthcare professionals, and care coordinators and the availability of the resources needed to carefully implement the project.
Project Implementation
The collected data and the resources will now be implemented in a certain community for the healthcare needs of a specific population like the elderly people. The implementation phase is the final phase which assures that the project is completed and now ready to evaluate.
Project Evaluation
The implementation phase leads to the evaluation phase because without determining the effectiveness of the plan it is not possible to generate effective and positive patient outcomes. The feedback of the population will determine the changes required in the plan.
Measures of outcome
Slide 10: The outcomes measurement is necessary to determine the gaps and defaults in the project along with the identification of the changes needed in the project. Different outcomes from various perspectives will be considered to evaluate the need for change in the plan. A few outcome measures are given below;
Medical Outcomes
The clinical outcomes on how the technology-based systems are working to produce enhanced patient experience regarding the care coordination provided to them along with the effectiveness of the staff leading as care coordinators in the project.
Patient Outcomes
The patient outcome is the most important outcome measure in the identification of the evaluation of the plan a project was developed for the elderly population do only a positive response can indicate the effectiveness of this project.
Financial Outcomes
The finance regarding the implementation of the plan and the cost of healthcare resources is necessary to evaluate the proficiency of the technology-based systems and their usability in increasing the positive patient response.
Outcome Measure of Sustainability
The measurement of how sustainable the project will be by identifying its outcomes based on the effectiveness of the care coordinators and the other resources including information technology-based healthcare services for the elderly population.
Presenting Project Plan to Administrative Decision-Makers
Slide 11: To effectively present the project to the decision-makers it is necessary to identify and present the goals and objectives of the project regarding the implementation of healthcare services provided to the patients and the elderly population (Irfan et al., 2021). The resources that will be utilized in the effective implementation of the project will also be determined and presented. The needs of the elderly population and preferences of the people for the type of care coordination should be provided to them and will be presented to the decision-makers for a better understanding of the end of the plan. After describing the purpose and goal of the project present the coordinated care model that will be implemented along with the integration of technology-based healthcare systems.
Provide a detailed explanation regarding the milestones, their time of achievement, and the cost and resources utilized for the effective development of the project (Yaghmour et al., 2021). The strategies for measuring the outcomes and the key indicators implemented to evaluate the quality of the project will also be presented to the administrators regarding the decision-making for the implementation of the care-coordinated plan. The proper assessment of risks related to a project and the plan to keep the effectiveness of the project sustainable will be provided in detail. At the end of the presentation, the decision-makers will be allowed to ask questions and conclude their perspectives regarding the suitability and effectiveness of the project.
NURS FPX 6618 Assessment 1 Conclusion
Slide 12: Coordinated care availability and effectiveness are the basic needs of all people around the world whether in a small rural community or an urban community (Bendowska & Baum, 2023). The elderly population ae more vulnerable to diseases therefore the need for a care coordinator should be fulfilled so that the proper care coordination plan will be implemented. The analysis of the preferences of the population, and the identification of the organizations and agencies needed to collaborate in the successful implementation of the care coordination plan is crucial. The resources needed to implement the plan with proper measurement of the risk associated with the project are all included in the effective planning of the project. The proper milestones with effective timing will be produced and presented to decision-makers to conclude the efficiency of the plan.
NURS FPX 6618 Assessment 1 References
Bendowska, A., & Baum, E. (2023). The significance of cooperation in interdisciplinary health care teams as perceived by polish medical students. International Journal of Environmental Research and Public Health, 20(2). https://doi.org/10.3390/ijerph20020954
Butler, J. M., Gibson, B., Lewis, L., Reiber, G., Kramer, H., Rupper, R., Herout, J., Long, B., Massaro, D., & Nebeker, J. (2020). Patient-centered care and the electronic health record: Exploring functionality and gaps. JAMIA Open, 3(3), 360–368. https://doi.org/10.1093/jamiaopen/ooaa044
Irani, E., Hirschman, K. B., Cacchione, P. Z., & Bowles, K. H. (2019). The role of social, economic, and physical environmental factors in care planning for home health care recipients. Research in Gerontological Nursing, 13(3). https://doi.org/10.3928/19404921-20191210-01
Irfan, M., Khan, S. Z., Hassan, N., Hassan, M., Habib, M., Khan, S., & Khan, H. H. (2021). Role of project planning and project manager competencies on public sector project success. Sustainability, 13(3), 1–19. https://doi.org/10.3390/su13031421
Junaid, S. B., Imam, A. A., Balogun, A. O., De Silva, L. C., Surakat, Y. A., Kumar, G., Abdulkarim, M., Shuaibu, A. N., Garba, A., Sahalu, Y., Mohammed, A., Mohammed, T. Y., Abdulkadir, B. A., Abba, A. A., Kakumi, N. A., & Mahamad, S. (2022). Recent advancements in emerging technologies for healthcare management systems: A survey. Healthcare, 10(10), 1–45. https://doi.org/10.3390/healthcare10101940
Karam, M., Chouinard, M., Poitras, M., Couturier, Y., Vedel, I., Grgurevic, N., & Hudon, C. (2021). Nursing care coordination for patients with complex needs in primary healthcare: A scoping review. International Journal of Integrated Care, 21(1), 16. https://doi.org/10.5334/ijic.5518
Khatri, R., Endalamaw, A., Erku, D., Wolka, E., Nigatu, F., Zewdie, A., & Assefa, Y. (2023). Continuity and care coordination of primary health care: A scoping review. BMC Health Services Research, 23(1). https://doi.org/10.1186/s12913-023-09718-8
Nicolet, A., Perraudin, C., Krucien, N., Wagner, J., Bridevaux, I., & Marti, J. (2023). Preferences of older adults for healthcare models designed to improve care coordination: Evidence from Western Switzerland. Health Policy, 132, 104819. https://doi.org/10.1016/j.healthpol.2023.104819
Northwood, M., Shah, A. Q., Abeygunawardena, C., Garnett, A., & Schumacher, C. (2022). Care coordination of older adults with diabetes: A scoping review. Canadian Journal of Diabetes, 47(3). https://doi.org/10.1016/j.jcjd.2022.11.004
Robertson, S. T., Rosbergen, I. C., Jones, A. B., Grimley, R. S., & Brauer, S. G. (2022). The effect of the electronic health record on interprofessional practice: A systematic review. Applied Clinical Informatics, 13(03), 541–559. https://doi.org/10.1055/s-0042-1748855
Shahid, R., Shoker, M., Chu, L. M., Frehlick, R., Ward, H., & Pahwa, P. (2022). Impact of low health literacy on patients’ health outcomes: A multicenter cohort study. BMC Health Services Research, 22(1). https://doi.org/10.1186/s12913-022-08527-9
Yaghmour, N. A., Poulin, L. J., Bernabeo, E. C., Ekpenyong, A., Li, S. T., Eden, A. R., Hauer, K. E., Tichter, A. M., Hamstra, S. J., & Holmboe, E. S. (2021). Stages of milestones implementation: A template analysis of 16 programs across 4 specialties. Journal of Graduate Medical Education, 13(2s), 14–44. https://doi.org/10.4300/jgme-d-20-00900.1
Young, M., & Smith, M. A. (2022). Standards and evaluation of healthcare quality, safety, and person centered care. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK576432/